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Revisiting the Evidence: Intraoperative Cholangiography during Cholecystectomy among Hospitalized Medicare Beneficiaries
*Elizabeth J Lilley, *John W Scott, *Wei Jiang, *Anna Krasnova, *Nikhila Raol, *Navin Changoor, Ali Salim, *Adil H Haider, *Joel S Weissman, *Eric B Schneider, *Zara Cooper
The Center for Surgery and Public Health at Brigham and Women's Hospital, Boston, MA

Objective(s): Previous retrospective studies reported reduced risk of common bile duct injury (CBDI) during cholecystectomy when intraoperative cholangiography (IOC) is used. However, studies have used bile duct reconstruction (BDR) to define CBDI, which may misclassify patients with hepato-pancreato-biliary or duodenal malignancy for whom BDR represents standard of care. We sought to 1) compare IOC performance and BDR incidence among cholecystectomy patients with benign or malignant disease; 2) examine whether IOC was associated with reduced risk of BDR in patients with benign disease; and 3) determine whether BDR was associated with increased mortality in patients with benign disease. Design: Retrospective cohort study using 2004-2011 national Medicare claims data to perform multivariable regression and survival analysis. Setting: Hospitalized care Patients: Patients, >65 years, who underwent inpatient cholecystectomy. Interventions: IOC during cholecystectomy Main Outcomes: BDR within 12 months of cholecystectomy; 12-month survival Results: 564,485 patients underwent inpatient cholecystectomy: 97.5% had benign disease. Compared to patients with benign disease, fewer patients with malignancy received IOC (11% vs. 35%), but more had BDR (11% vs. 0.4%). Among those with benign disease (N=550,328), IOC was associated with increased odds of BDR (adjusted OR 1.18 [1.08-1.29]), and BDR was associated with increased hazard of death in 12 months (adjusted HR 1.64 [1.48-1.82])(Figure). Conclusions: Although fewer patients with malignancy received IOC, more had BDR suggesting that using BDR as a proxy for CBDI may introduce confounding by indication. These data do not demonstrate reduced risk of CBD injury when IOC was performed in patients receiving cholecystectomy for benign disease.

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